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Breast Reconstruction

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Definition

Breast reconstruction is plastic surgery to rebuild a breast. It is usually done after a mastectomy (removal of the breast) has been done to treat cancer. Reconstruction generally requires several stages. The first stage may be done at the time of mastectomy (immediate reconstruction) or at some point after the mastectomy (delayed reconstruction). Breast reconstruction can be done using an implant or tissue expander followed by placement of an implant. Breast reconstruction can also be done using a tissue flap taken from another part of the body.
Breast Reconstruction With Implant
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Reasons for Procedure

The goal of the procedure is to create a reconstructed breast that appears as similar to the natural breast as possible.

Possible Complications

Complications are rare, but no procedure is completely free of risk. If you are planning to have a breast reconstruction, your doctor will review a list of possible complications which may include:
  • Bleeding
  • Infection
  • Pain
  • Reactions to anesthesia
  • Fluid or blood-filled cysts in the healing breast tissue
  • Abnormal scarring
  • Painful and/or restricted arm and shoulder motion
  • Uneven appearance of breasts, due either to position or size
  • Implant may harden, rupture, or leak
  • Implant may make cancer detection (through mammogram and/or self-exam) more difficult
  • Newly reconstructed breast will not have nerve sensation
  • The need to have more surgeries, including having the implants removed
Some factors that may increase the risk of complications include:
  • Obesity
  • Smoking
  • Bleeding disorder
  • Malnutrition
  • Chronic illness or debilitation such as heart disease or lung disease
  • Prior radiation therapy to the chest wall, which may make healing more difficult
  • Chemotherapy
Silicone-filled breast implants are not designed to last a lifetime. They typically need to be removed within 10 years. Your risk for complications increases the longer you have the implants.

What to Expect

Prior to Procedure

The following may be done:
In the days leading up to the procedure:
  • Talk to your doctor about the medications you are taking, including over-the-counter drugs and supplements. Some medications may need to be stopped for one week before surgery.
  • Arrange for a ride to and from the procedure.
  • Arrange for help at home after the procedure.
  • The night before, eat a light meal, and do not eat or drink anything after midnight.
  • You may be asked to shower the morning of your procedure. You may be given antibacterial soap to use.

Anesthesia

General anesthesia is most often used for this procedure. It will block pain and keep you asleep through surgery.

Description of the Procedure

Implant Procedures
When you are asleep and no longer feel any pain, a breathing tube will be placed.
A breast implant is the simplest form of reconstruction. It can be done at the time of mastectomy if there is enough skin left on the chest wall. This one-stage, immediate breast reconstruction procedure involves inserting a breast implant where the breast tissue was taken out. The implant can be a silicone shell filled with sterile salt water (saline) or silicone gel. Alloderm or another type of treated skin may also be used to improve the appearance of the reconstructed breast. This type of reconstruction may provide an improved appearance of the breast without resorting to the use of skin and muscle tissue flaps. It is becoming the method of choice in immediate breast reconstruction.
Two-stage reconstruction is done if your skin and chest wall tissues are tight and flat. A tissue expander (temporary implant) is slipped under the skin, and the skin is closed. The expander can then be filled with saline. Over a few weeks, more saline is gradually put into the pouch with a needle. The skin overlying the pouch slowly expands as the pouch grows in size. Some doctors leave this expander in place as the actual implant. Others will replace the tissue expander with a saline or silicone gel implant. This replacement requires additional surgery.
If you want the size, shape, and color of your nipple and areola reconstructed, another surgery may be needed. The nipple can be reconstructed using local tissue. The areola can be reconstructed using skin from the inner thigh. Proper coloring is achieved through tattooing.
Tissue Flap Procedures
More complicated types of breast reconstruction involve using muscle and skin flaps from the abdomen, back, or other parts of your body.
The transverse rectus abdominis muscle (TRAM) flap procedure takes tissue and muscle from the lower abdomen and creates a breast shape. It is then moved to the chest area. Skin, fat, blood vessels, and abdominal muscles are removed, resulting in a tummy tuck. Two types of TRAM flaps exist:
  • A pedicle flap remains attached to the original blood supply under the skin from the abdomen.
  • A free flap is completely cut away from its original location and reattached to blood vessels in the chest area using microsurgery. New advanced techniques may decrease complications and recovery time.
Other procedures include:
  • Gluteal-free flap procedure (less common)—Tissue is taken from the buttocks and reconstructed to form a breast shape. New advanced techniques may decrease complications and recovery time.
  • Latissimus dorsi flap (common)—Skin and muscle is taken from the upper back and tunneled under the skin to the front of your chest.

Immediately After Procedure

After the operation, you will be taken to the recovery room for observation.

How Long Will It Take?

About 2-6 hours

How Much Will It Hurt?

Anesthesia prevents pain during surgery. You may experience pain after the surgery and during the healing process. You will be given pain medication.

Average Hospital Stay

You may be in the hospital up to a week if your procedure is done at the same time as a mastectomy. If there are any complications, your hospital stay may be longer.

Post-procedure Care

At the Hospital
Right after the procedure, you will be in a recovery room where your blood pressure, pulse, and breathing will be monitored. Recovery may also include:
  • Medication to control nausea
  • Gradually returning to your normal diet
  • Using an incentive spirometer to help you breathe deeply
If you have a tissue expander, you will need to have additional saline added gradually. Your doctor will set the schedule.
During your stay, the hospital staff will take steps to reduce your chance of infection such as:
  • Washing their hands
  • Wearing gloves or masks
  • Keeping your incisions covered
There are also steps you can take to reduce your chances of infection such as:
  • Washing your hands often and reminding visitors and healthcare providers to do the same
  • Reminding your healthcare providers to wear gloves or masks
  • Not allowing others to touch your incisions
At Home
When you return home, follow these steps:
  • You will gradually return to your normal activities.
  • You may be given compression stockings to reduce your risk of blood clots.
  • For silicone gel implants, you will need routine screenings to check for ruptures. The screenings are typically done 3 years after surgery and every 2 years after that.

Call Your Doctor

After you leave the hospital, contact your doctor if any of the following occurs:
  • Signs of infection including fever and chills
  • Redness, swelling, increasing pain, excessive bleeding, or discharge at the incision site
  • Pain that you cannot control with the medications you have been given
  • Nausea and/or vomiting that you cannot control with the medications you were given after surgery, or which persist for more than two days after discharge from the hospital
  • Implants grow hard or you believe that they are leaking
  • Joint pain, fatigue, stiffness, rash, or other new symptoms
  • Pain and/or swelling in your feet, calves, or legs, sudden shortness of breath or chest pain
In case of an emergency, call for emergency medical services right away.

RESOURCES

American Cancer Society http://www.cancer.org

Breastcancer.org http://www.breastcancer.org

CANADIAN RESOURCES

Canadian Breast Cancer Foundation http://www.cbcf.org

The Canadian Society of Plastic Surgeons http://www.plasticsurgery.ca

References

Nahabedian MY. AlloDerm performance in the setting of prosthetic breast surgery, infection, and irradiation. Plast Reconstr Surg. 2009;124(6):1743-1753.

Namnoum JD. Expander/implant reconstruction with AlloDerm: recent experience. Plast Reconstr Surg. 2009;124(2):387-394.

Breast reconstruction. Breastcancer.org website. Available at: http://www.breastcancer.org/treatment/surgery/reconstruction. Updated September 4, 2014. Accessed September 8, 2014.

Silicone gel-filled breast implants: updated safety information. US Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm260235.htm. Published June 22, 2011. Accessed September 8, 2014.

7/1/2011 DynaMed's Systematic Literature Surveillance. http://www.ebscohost.com/dynamed. FDA provides updated safety data on silicone gel-filled breast implants. US Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm260235.htm. Published June 22, 2011. Accessed September 8, 2014.

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